HealthManagement, Volume 10, Issue 4 / 2008

The UK Health and Hospital System

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Dr. Andrew Corbett-Nolan FRSM FCQI MHSM,


Institute of Healthcare Management, United Kingdom


[email protected]

The United Kingdom (UK) is comprised of En gland, Scotland, Wales and Northern Ireland and is situated within the British Isles. A constitutional monarchy gover n ed from Parliaments in London and Edinburgh, and As semblies in Cardiff and Belfast, the UK is a stable and mature democracy. Indeed, the current constitutional monarch Queen Elizabeth II, traces her direct descent from the last successful invasion of England in 1066.


The national Parliament at Westminster has been control led since 1997 by a Labour Party administration, and the Prime Minister changed to Gordon Brown in 2006. A sign of the political stability is that Mr. Brown is just the fourth Premier since 1979.


The Labour administration has sought to increase funding from taxation for the welfare state, and in particular has funded significant increases in healthcare to bring the UK healthcare spend to the European national average by 2010.


Healthcare in England reports to the national Parliament at Westminster via the Secretary of State for Health (currently

the Rt. Hon Alan Johnson MP), while for Scotland it reports to the local Parliament and in Wales to the Assembly. Social care is funded and managed through the local authority system of Councils.


Population, Demography and Languages

In 2006 the total UK population topped 60 million, with 50.7 m living in England, 5.1 m in Scot - land, 2.9 m in Wales and 1.7 m in Northern Ireland. The average age was 39.0 years, having risen from 34.1 in 1971. Today, one in five in the UK is aged under 16, and one in six is over the age of 65. The population has grown 8% in the last 35 years.


Death rates have continuously fallen in the UK, and in 2006 502,599 deaths were registered with rates per million of the population being 7,123 for men and 4,989 for women. In 1900 around half of all deaths were for people aged 45 or under, and by 2006 this had been reduced to 4%. Life expectancy at birth is now 81 for women and 76 for men. At age 65 male life expectancy is now 81, and female life expectancy 84.


English is the main native language, with Welsh being a second official language in Wales. However, the UK is a highly cosmopolitan country. In London, some 300 languages are spoken and there are some 50 nonindigenous communities with a population exceeding 10,000. Around 40% of London’s population are from an ethnic minority group, and nearly 30% was born outside the UK.


The Economy

The economy is strong, with a gross domestic product of £1.209 billion (1.522 billion euros) in 2005 and an annual GDP

growth in 2007 of 3.1%. This makes the UK the fifth largest economy in the world on the basis of market exchange rates.


In 2006 average income in England was £34,197 or 43,064 euros (within a range from London at £46,228 to £27,405

in the North East). However, first home prices start from 2.8 times average income in the North East but 4.8 times average income in London.


The employment rate in 2006 was 74.9%, and the unem ployment rate 5.3%. 819,300 un employment benefit claimants were chasing 678,600 vacancies in May 2008. Inflation for consumer prices currently stands at 3.3%.


Public Health

In 2005 239,000 new cases of malignant cancer were diagnosed in England, more than half of which were breast, lung,

colorectal and prostate. One in three of the UK population will develop cancer during their lives, and one in four will die from it. In 2005 126,600 people died from cancer in England. Five year survival rates range from 3- 16% for cancers of the pancreas, lung, oesophagus and brain, 50% for colon cancer and 81% for breast cancer. Survival rates for most cancers improved during the 1990s.


Regarding health risk factors, 24% of adults in the UK smoked cigarettes in the UK, this having declined from 45% in 1974. The Government aims to reduce this to 21% by 2010. 35% of adults exceed the Government safe drinking guidelines, with 72% of men and 57% of women having consumed an alcoholic drink within the past week in 2005.

Drinking is higher in younger adults, with 42% of men aged 16-24 having exceeded the safe drinking limited on at least one day during the previous week. Just 14% of men and 27% of women consume the recommended five portions of fruit of vegetables a day, and 67% of men and 58% of women are overweight.


Sexually transmitted diseases have significantly increased, with there being a 5% rise of Chlamydia diagnoses at sexual

health clinics between 2004 and 2005. Some 63,500 people in the UK live with HIV infection with 2005 showing a record increase of 7,450 new cases.


The National Health Service (NHS)

In the United Kingdom, all British subjects are entitled to access healthcare free at the point of delivery from the National Health Service (NHS). Founded in 1948 and this year celebrating its 60th anniversary, the NHS is a unique national institution. The NHS is the largest employer in Europe with just over 1.3 million staff. There were in 2005 679,157 professionally qualified clinical staff in the NHS, including 122,345 doctors, 404,161 nurses and midwives and 18,117

ambulance support staff. There were 39,391 managers and senior managers. Pay accounts for around 65% of the NHS budget.


Focussing on England, healthcare is funded by taxation at £92.2 billion (116.1 billion euros) for 2007. Some 83% of this is controlled by the 152 Primary Care Trusts (PCTs). PCTs are responsible for managing through contracts with general practitioners and secondary care organisations the healthcare needs of their local resident populations. Currently, PCTs also have some directly managed services.


General practitioners are selfemployed, working under national or local contractual arrangements to provide primary care to local patients registered with them. Other primary care providers, in part funded by the NHS through contracts, include community pharmacists, opticians and dentists. Patients of working age generally make copayments to access these nonmedical clinical professionals. In 2003 there were 10,683 general practices in the UK with 39,920 individual general practitioners. The average list size per practice was 5,891 in England, 5,885 in Wales and 5,095 in Scotland. In 2005 87% of general practictioner consultations took place in the surgery, 9% over the telephone and 4% in the patient’s home.


Though there is a small private healthcare insurance and provision sector in the UK, the majority of all secondary care is

provided by NHS organisations. In England these are termed NHS Trusts or NHS Foundation Trusts, the latter having in creasing earned independence from central control, this being achieved on the basis of sustained good financial management and good quality ratings from the regulator.


The 570 Trusts tend to divide into those specialising in acute secondary care and others for mental health services. The

intent is that over the coming few years all NHS Trusts migrate to becoming NHS Foundation Trusts. The NHS runs a number of central programmes to support local delivery. These include NHS Direct, a unique national telephone helpline open 24 hours a day which can offer immediate nurse-led advice to callers, or arrange for a doctor to call the patient.


This helpline provides detailed information and advice to callers, including details of local service access arrangements, advice on self care and on those cases where the patient needs to access more immediate care. The NHS has invested heavily in quality in the last decade, and in England all healthcare services are regulated by the Healthcare Commission. This institution rates NHS organisations on an annual basis, registers private healthcare establishments and conducts investigations into service failures. It is planned that in 2009 this organisation will merge with the comparative social care ins pectorate and form the Care Quality Com mission.


Other central quality initiatives include the National Patient Safety Agency (NPSA), which aims to support the NHS reduce the number and significance of clinical errors.


The National Institute for Health and Clinical Excellence (NICE) provides ad vice on good health and the prevention and treatment of ill health. Taking a thorough and robust evidence-based approach, NICE provides guidance on health technologies and clinical practice, taking into account both proven benefits to patients and cost effectiveness.


Managing the Healthcare System

In the UK, healthcare managers come from a variety of professional backgrounds. As far as NHS chief executives (CEOs) are concerned, a minority will have clinical backgrounds (mostly nursing) while most will be from general management or finance backgrounds. CEO pay for local healthcare organisations has increased 70% in the past decade.


The average pay for acute hospitals was £112,500 (141,670 euros) with the top paid hos pital CEO earning £215,000 (270,000 euros). PCT CEOs aver age around £92,500 (116,000 euros). With managers coming from a variety of professional backgrounds there are different professional development and career options open to aspiring healthcare leaders.


The uni-pro fessional healthcare management organisation is the Institute of Healthcare Mana ge ment (IHM), which was founded in 1902. With around 6,000 members IHM works to develop healthcare managers in the UK through training, accreditation schemes and a code of managerial ethics (see article on p. ).


Plans for the Future

As it approaches its 60th anniversary, the NHS reform agenda continues. In response to international trends in healthcare inflation, an ageing population, increased public expectation and continually improving healthcare interventions, the NHS has in place significant plans for change. In England, these include devolving all healthcare provision responsibilities away from PCTs in order that they can become local healthcare benefit organisations which hold the public funds for health and healthcare for the local population.


PCTs are increasingly being asked to consider the healthcare risk held within their local population and to craft both healthcare services to meet current needs and wellness programmes to reduce the burden of ill-health over time.


The NHS has a policy of encouraging competition and pluralism in terms of providers, and is charged with both modernising current NHS providers through the NHS Foundation Trust programme and by bringing in new private and independent sector care providers. The aim is to both sharpen performance and increase patient choice.


Ending 2007 in financial surplus, the NHS continues to drive through efficiencies and improvements. Year on year the productivity and outcome targets are revised upwards for the NHS, increasingly linking to other metrics intended to improve public services overall.


Current development themes include closer working with social care, consideration of new ways of caring for patients outside hospitals and the steady decrease of health inequalities within the different communities in the UK.


Nationally, the NHS continues to promote best practice through unique agencies charged with system development, quality, safety, the increased use of information technology and public health. Working as partners with professional and special interest groups the NHS is set to ensure that it remains a unique national asset to the people of the UK by the time of its 100 anniversary in 2048 and beyond.

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